LIFE IN THE END ZONE: A discussion of topical issues for anyone concerned with the final phase of life by Muriel R. Gillick, MD

September 01, 2014

Penny Wise, Pound Foolish

What drove me crazy about practicing medicine in a nursing
home wasn’t the patients, although with their many medical problems often
including cognitive impairment they were a challenge; and it wasn’t the
families, though with their anxiety and attentiveness and sometimes their guilt
they were an even greater challenge. What drove me crazy about nursing home
medicine was Medicare billing.

When I saw patients in the nursing home, I was hemmed in by
the fact that Medicare had a very clear idea of what constituted an appointment
with a nursing home patient. According to Medicare, a “visit” (billing jargon)
entailed a face to face “encounter” (more billing jargon) between a “clinician”
(in this case, me, the physician) and the patient.

Once the patient and I were in the same room, I had a script
to follow. I was first supposed to take a “history,” (medicalese for eliciting
symptoms); then I was supposed to do a physical exam, which involved specified
“elements” (examination of particular bodily parts). Finally, I was supposed to
engage in “evaluation and management,” which might result in ordering lab tests
or prescribing a medication. The problem was that in the nursing home
environment, a history and physical, to be useful, looked very different from
what Medicare had in mind. Many of my patients were demented and couldn’t
possibly give a coherent history. Moreover, many of those who had relatively
mild dementia could always be counted on to complain about something, so if it
had been up to the patient, I would have made a visit every day. Many of the
patients had medical conditions that required observation over a prolonged
period, not just at one point in time. For example, a patient with dementia
might have paranoid delusions that significantly affected his or her quality of
life, but those delusions would come and go. A patient with Parkinson’s disease
might have difficulty walking that fluctuated over the course of the day,
depending both on random changes and on when the patient last took medication. As
a result, the most meaningful history and the most useful physical observations
had to be obtained secondhand—from nurses, nurses aides, and other staff
members including physical therapists and social workers. I spent much of my
time interviewing personnel about my patients, time that Medicare did not
recognize as valuable because it was not part of an “encounter.”

Starting in January, 2015, Medicare will pay a special
monthly “complex chronic management” fee on top of the usual reimbursement to
primary care patients who care for patients in
the office. But somehow the nursing home environment is assumed to be
immune from the need for this kind of supplementary support. Calls to family
members and discussions with other members of the interdisciplinary team are
supposed to be part of the “evaluation and management” services that are
“bundled” into the Medicare fee schedule. So it’s thought to be perfectly
reasonable for a physician to be paid $92 in 2015 for a nursing home visit for an acute
medical problem such as a new pneumonia (code 99309). To merit this payment, the physician must provide
documentation that he or she has taken 2 out of 3 possible steps: obtained a
detailed history, performed a detailed physical exam, or engaged in “moderately
complex” medical decision making. Only if the physician takes a comprehensive history,
performs a comprehensive exam, and engages in highly complex medical
decision-making can he or she bill with the code“99310,” earning the somewhat more generous sum of $136.
For comparison, note that a gastroenterologist is paid on average $220 for
performing a colonoscopy, a 20-minute procedure.

No wonder physicians often respond to a call from the
nursing home about a sick patient with an order to send the patient to the
hospital for evaluation. Send a frail nursing home patient to the emergency room and he
has, I would guess, about a 90% chance of being admitted. So instead of paying
a physician an appropriate amount for making a visit to the nursing home and
instituting on-site medical care, Medicare would fork out a minimum of $5774
(the base DRG payment) for a 5-day hospitalization, exposing the patient to the
risk of iatrogenesis. Does this make any sense?